3 firms that specialize in dealing with HMOs one's for patients only

Staying Ahead

November 16, 1998|By Jane Bryant Quinn | Jane Bryant Quinn,Washington Post Writers Group

ENOUGH patients doubt their doctors and health plans today to create a new medical service: the independent advocate. Advocates stand on your side of the table. They advise on a wide range of issues, from the quality of your medical care to how to get an HMO to pay a bill.

I'm aware of three nationwide services, so far. Each has a different approach to dispensing advice.

American Medical Consumers (AMC), in La Crescenta, Calif. (800-836-5262), is aggressively pro-consumer. It helps you make health care decisions, resolve disputes and get better medical attention. It also explains your medical rights.

Founder Dr. Vincent Riccardi, an internist and clinical geneticist, takes the calls and dispenses advice. You pay $20 for a single session. A year's worth of help, for any medical problem you have, costs $135.

Sue J. of New York City (she doesn't want her last name used) turned to AMC when her HMO wouldn't pay for her $6,400 breast reduction operation. She needed the surgery to alleviate back pain and bruised ribs.

For nearly a year, the HMO wouldn't give her a reason for turning her down. Eventually, it claimed that the surgeon hadn't taken enough grams of tissue for her to qualify.

Riccardi told Sue how to request her HMO's policies and procedures for denying claims. He also said that the HMO shouldn't consider grams alone, without relating them to her size (she's just 5 feet 1 and of medium weight).

"In the end, they agreed to pay for almost everything," Sue says.

Diane Berrent of Sonoma, Calif., says Riccardi helped her spot overbilling by a private-pay doctor, and taught her how to exercise her rights within her HMO.

Riccardi has also relieved the minds of patients who got good advice from the HMO but didn't believe it -- because their doctor had lost their trust.

Riccardi urges patients to get copies of their medical records and challenge those that are inaccurate or incomplete.

"Often, the doctor doesn't write down all the key things that the patient talked about," he says.

A doctor's written word takes precedence over a patient's statement.

You might be turned down for treatment some day, if your doctor hasn't documented a pattern of symptoms over time.

Riccardi has talked to about 1,100 consumers in the past two years. About 100 have signed up for year-round consultations.

CareCounsel in San Rafael, Calif. (888-227-3334), signs up employers who want to offer medical advice to employees and their families. It has four contracts so far, and covers about 15,000 people, says Dr. Larry Gelb, a psychologist and president of the firm.

Employees phone for help in choosing among health plans, understanding managed-care rules, picking a specialist, understanding a disease they've just been diagnosed with, and resolving disputes. "Health plans are often cumbersome bureaucracies," Gelb says. "It's hard for people to get their needs met."

The calls employees make are confidential. But Gelb reports to employers on the types of complaints he gets, to help them evaluate the quality of the health plans they offer.

It was quality that drove Lon Records to CareCounsel. He's president of Target Specialty Products in Santa Fe Springs, Calif., a wholesale distributor of pesticides and chemicals.

In two cases, he'd had to intervene personally with insurers to get treatment for employees with life-threatening conditions.

Now, Records is paying about $1 per person each month for CareCounsel to be his ombudsman. "From an employer's perspective, it gives you a great deal of peace of mind," he says.

CareCounsel has a separate service for cancer patients, which you can sign up for individually.

You pay $128 for general medical consultation, plus $800 to $1,250 to have your records reviewed by Memorial Sloan-Kettering Cancer Center in New York.

Sloan-Kettering has suggested different treatments in 17 percent of the cases, Gelb says.

Six-year-old Health Decisions International (HDI), in Golden, Colo. works with both employers and health plans. About 5 million people have access to HDI's services, says the company's chairman, internist Dr. Donald Vickery.

HDI is chiefly an information source, not an advocate. It tells you what's known about the risks and benefits of the various treatments for a particular illness.

That helps you make better medical decisions. Informed patients are happier patients, and generally use fewer medical services, Vickery says.

HDI also offers advice on prenatal care, healthy lifestyles and managing chronic disease -- all at about 70 cents per member per month. But it doesn't review medical records or handle coverage disputes. There, you're on your own.

Pub Date: 11/16/98

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